Provider Demographics
NPI:1841783958
Name:MOUCHAHAM, NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:MOUCHAHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 LAKE HILL CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2328
Mailing Address - Country:US
Mailing Address - Phone:765-729-2236
Mailing Address - Fax:
Practice Address - Street 1:9310 N MERIDIAN ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-0001
Practice Address - Country:US
Practice Address - Phone:317-846-6125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012945A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice